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i <br /> Backwater Prevention Device Rebate Program <br /> t„ Rebate Application Form <br /> � Property Owner Name �� �✓� M -Q,I . . -- <br /> Installalion Address' Z I ZZ !�a��i+ C���- <br /> Clty �,��'_�,`.•}'t --- State: LJ�--Zip:�I�Zv � — -- <br /> Mailing Address (if diHerentJ:_ <br /> City: _ ____ State: Zip:_ <br /> Email: _ Phone: ( ) _ <br /> Total Cosl to Install Dovice (/rem contractor invoice): 5 2�oU . (o $ <br /> Please verify the following: <br /> ;� I am the owner of ihe property where the backwater prevenlion device was installed. <br /> � I worked wilh lhe contractor lo determine the locafion for the backwater pre�:ntion device and <br /> understand that the decision regarding the localion of the device was mine. <br /> ,�G] My contracter instructed me how!o access, inspect,and maintain the device. � <br /> � I undersfand that I am responsible for maintaining the backwater prevention device and keeping <br /> il in good working order, unless it is installed in ihe ciry nght-of-way. <br /> �. If I sell my property, I will make potential buyers aware of the backwaler prevention device and <br /> the need to inspect and maintain it on a reguiar basis. <br /> � I am enclosing all of lhe necessary paperwork(use the yellow Rebate Suhmidal Checklist). <br /> Seiect irom the foilowing: <br /> j,R� The contracbr identified downspouts or other drainage Ilines that were connected to my sewer <br /> line (between my house and ihe installed device)and removed, or rerouted them. <br /> �(J To my knowledge, my property has no downspouts or other drainage connected to my sewer line <br /> (between my house and the installed device). <br /> � There are downspouls or other drainage lines connected to my sewer line (behveen my house <br /> and tho installed devlce) I understand that Ieaving these conneclions creates a nsk of flooding <br /> and I accept that risk. <br /> � <br /> 1 r / / �7 ��' <br /> Signafure 1�✓�'�^'f�W _ Date �/ �/L ' /� <br />